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HomeMy WebLinkAbout2024-00067886 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 OIl III (III III lull 1111111111111111 IIIIIIIIIIIIIIIIII II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003599340' u, 1 U21 2 4 1 U1 2 U2 1 U, 1 U2 1 U1 1 U2 1 1 15 Ut 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury J Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ill OVER$1.500 ❑AMENDEDEl NOT ON CENE(DESK REPORT) ® B Injury and JorTow Due To Crash YR 2O24I2O24-00067886 VENT * ADDRESS NO. •HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 't'I S LIBERTY ST Elgin ❑ RELATED ®Y ❑N 10 24 2024 02:10 ❑AM ❑YES ®NO U1 ,< PRIVATE mo /day I yr ®PM FLOW CONDITION m FT/MI N E 5 W JAY ST 'COUNTY PROPERTY ❑Y M N DOORING ❑y #OF MOTOR ❑SLOW 1 U) El COOK HIT&RUN ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I El AT INTERSECTION WITH (NAME OF ) PEDALCYCUST El ® FREE FLOW # LNS 0 tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIN ❑NCV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n 0 8 / 3 1 J 2 O 0 5 FOR DAMAGED AREA(S) Hto 4T TOWED Ut O NAME(LAST,FIRST,M) mo day yr Buick Enclave 2009 00-NONE �.i O.,/1 DUE TO CRASH ® ❑ E 13-UNDER CARRIAGE lJ FIRE ❑ SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) ® O DISTRACTED 0 ® U2 0 m 433 ILLINOIS AVE F SYM ❑Y ®SNE❑UNK VEH. O AT CRASHD 0 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN = IN CITY PLATE NO. STATE YEAR POINT OF 8 i 6 1 i+ 4 COM VEH 0 El 1 O FIRST CONTACT 12 7_ :{_�5 ^Yves,See Sidebar U1 0 Z 5GAER23D79J218824 No inusrance ®Y ❑N U2 m V. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Lira Vega. Doreidy No insurance 1 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER L RESPONDER II 433 ILLINOIS AVE. ELGIN , IL.60120 (630)641-5593 VEHU 0 5 ®DRIVER ❑ PARKED 0 CRNERLESS ❑ PED ❑PEDAL ❑EQUES 0 WV ❑NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) U1 2 m m / J FOR DAMAGED AREA(S) FRONT TOWED Y N s Martinez.Jajaira. D. 0 6 1 3 1 9 9 9 Mercedes-Ber12280 2007 00-NONE O 1 0 IN 0 2 XI NAME(LAST,FIRST,M) 1 mo day yr 9 wi z FIRE ❑ ® U2 C v 13-UNDER CARRIAGE , STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPOR C0 SYSTEM IN 0 ENGAGED O 15-OTHER 9 16-TOP 3 9 O E 675 VARSITY DR F ❑Y ® N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 07 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR p R- POIST COONTACT F 12 y _6_ -5II , CIO�VSee SidebaEH ❑ ® U1 ~ • rC ELGIN IL 60120 0 ED73586 IL 2025 " 0 Cn D TELEPHONE DRIVER'S LICENSE NO. STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 (847)766-4059 M635-4249-9768 IL D 0 WDBRF92H57F888411 United Equitable ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER 1 I Same PPQ0036174 BAG 3 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER 996 < RESPONDER Same U1 = (UNIT) I SEAT) (DOBi (SEX) i(SAFT) (AIR) (INJ( (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 1 09 /27/2012 F 2 3 0 1 0 Anniley Ambriz/433 ILLINOIS AVE.ELGIN.IL.60120 Refused 996 ,- (630)641-5593 , U2 m 2 4 09 /1 3/2021 F 12 3 0 1 0 Ellie E. Martinez/120 N SMITH ST-Aurora,IL,60505 Refused #OCCS D (847)766-4059 _ X / / Ut 2 m / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ❑AM Did crash occur ❑Y U2 Z N ® 11 1 10/24 /2024 02 10 0 PM in a Work Zone? ®N DIRP CO 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME It YES check one below: T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP0 AM Ut 7 2 0 2 99 / / PM ❑Construction * N 3 ❑ ®CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME AM ❑Maintenance U2 5 Ei Q •® 11 1 ARREST NAME Ambriz.Yomira 6-101 1500000289 / / El PM SLMT o U ®CITATIONS ISSUED 0 PENDING 'SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility p N AM 35 2 0 ARREST NAME Ambriz.Yomira 3-707 1500000290 10/24 /2024 02 50 ®PM 0 Unknown work zone type Ut T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1500-Chew. Marie 401 272-Bajak 11 , 18/2024 09 00 0 PM Workers present? ®N U2 35 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. _ F MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS ; I A _� } A CMV is defined as any motor vehicle used to transport passengers or property and. N 01 Has a weight rating more than 10,000 pounds(example truck or truck/trailer { r ', ', combination) or —I r INDICATE NORTH XI rn I : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C -I 1 d i o o Scale I. ` r r r r (example.shuttle or charter bus)-or N le 1' ] � 3. Is designed to carry 15 or fewer passengers and operateda contract carrier 0 <____a____ ; ; , unnz } ttransportingemployment byple employee_ employeesin the course of their e e a � ` transporter-usually a van type vehicle or passenger ca) or u I /I : r QI i_____A____. : i . : } r , 4 Is used or designated to transport between 9 and 15 passengers,including the driver, �l_ -- r for direct compensation(example.large van used for specific purpose).or L_ -:_____1 ; I. - i i 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example placards will be displayed on the vehicle) 71 \ 1 .7 Jo st CARRIER NAME Z .. ADDRESS 0 N CITY/STATE/ZIP MOTOR CARR ID ❑ Interstate ❑ Intrastate ❑ Not in Comm./Govt. Not in Comm./Other USDOT NO. ILCC NO. , Source of above Z . If Yes Name on placard 0 4 digit UN NO. 1 digit Hazard class No P3 XI m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? ❑ Yes ❑ No ❑ Unknowr D Did HAZMAT Regulations violation contnbute to the crash? r ❑ Yes ❑ No ❑ Unknown D Did Carrier Safety Regulations(MCS)violation contribute to the crash ❑ Yes 0 No ❑ Unknown A C Was a driver/vehicle Examination Report Form completed? D HAZMAT ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑ No - MCS ❑Yes ❑ No ❑Unknown Out of Service ❑Yes ❑No Form Number 0 m XI IDOT PERMIT NO WIDELOAD? ❑Yes ❑No S TRAILER VIN 1 m N LOCAL USE ONLY TRAILER VIN 2 m rJ TRAILER WIDTH(S) 0-96'1 97-102'1 >10; m m TRAILER 1 ❑ ❑ ❑ Z TRAILER 2 ❑ ❑ ❑ 0 U 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft 2 't Z Gray WhiteEn u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES DUE TO ❑X DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT. 3 TOWED BY/TO. DUE TO ❑ © Arties/Impound Lot Garage VEHICLE CONFIG _ CARGO BODY TYPE LOAD TYPE